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Objective: To test the hypothesis that a brief formalized period of wheelchair skills training, added to the standard curriculum, results in significantly greater overall improvements in wheelchair skills than a standard undergraduate occupational therapy (OT) curriculum alone., Setting: Rehabilitation center., Design: Randomized controlled trial., Participants: Eighty-two students in a university undergraduate OT program., Interventions: All students received the standard university curriculum. The 22 second-year students, randomly allocated to the Wheelchair Skills Training Program (WSTP) group, were also trained (on a single occasion each, in groups of 1-3 at a time) on the 50 skills that make up the WSTP. The mean +/- standard deviation (SD) training time was 121.2+/-33.5 minutes per group., Main Outcome Measure: Total percentage score on the Wheelchair Skills Test (WST), Version 2.4., Results: From before to after intervention, second-year students in the WSTP group increased their mean percentage WST scores +/- SD from 64.8%+/-9.0% to 81.0%+/-5.2%, a 25% improvement (P<.001). Over a comparable period, the 18 students in the second-year control group increased from 66.0%+/-8.0% to 72.4%+/-7.1%, a 9.7% improvement (P=.015). The WSTP group improved to a significantly greater extent (P=.005). For a subset of 8 students in the WSTP group who were retested 9 to 12 months later, the mean WST score was 79.7%+/-4.1%, not significantly less than their WST 2 scores (P=.29). The mean WST score for the 42 students in the fourth-year control group was 73.9%+/-4.1%, significantly lower than the mean postintervention WST score of the second-year students in the WSTP group (P< .0001) and not different from the second-year control group (P=.58)., Conclusions: The WSTP is an effective way to improve the wheelchair-skills performance of OT students. This has implications for the education of all rehabilitation clinicians.

Objective: To test the hypotheses that, during wheelie training, adding the proactive balance strategy (PBS) to the conventional reactive balance strategy (RBS) increases the success rate, decreases training time, and lessens postural sway during the wheelie., Design: Randomized controlled trial., Setting: Kinesiologic laboratory in a rehabilitation center., Participants: Twenty-two participants (12 wheelchair users, 10 able-bodied) randomly assigned to the RBS group or to the PBS+RBS group; the groups were balanced according to gender, age, and diagnostic category., Intervention: Participants were trained to perform stationary wheelies in 2 highly structured settings., Main Outcome Measures: Success rate in achieving wheelie competence, training time, and postural sway on a force platform., Results: Success rate was 100% for both groups. The RBS group required a mean +/- standard deviation of 43+/-31 minutes of training time and the PBS+RBS group required 45+/-28 minutes (P=.54). There was no significant difference between training groups with respect to postural sway measures (P=.50). Age correlated with both training time (r=.70, P=.001) and postural sway (r=.52, P=.03). Qualitatively, we identified 3 take-off patterns and confirmed the use of the 2 balance patterns., Conclusions: The addition of the PBS to RBS training did not improve wheelie success rate, training time, or postural sway. Although older wheelchair users require more training time, many such users can learn this useful skill if given the opportunity.

Objective: To evaluate the measurement properties of the Wheelchair Skills Test (WST), version 2.4., Design: Cohort study., Setting: Rehabilitation center., Participants: A total of 298 subjects (169 wheelchair users, 129 able-bodied subjects) ranging in age from 17 to 88 years., Intervention: We videotaped subjects as they attempted the 50 skills of the WST 2.4., Main Outcome Measures: The test-retest, intrarater, and interrater reliabilities were determined on a subset of 20 wheelchair users. We assessed construct validity by evaluating whether the WST detected expected changes and concurrent validity by seeing how well total WST scores correlated with criterion measures., Results: The mean time +/- standard deviation taken to administer the WST was 27.0+/-9.3 minutes. There were no serious adverse incidents, and the test was well tolerated. For the test-retest, intrarater and interrater reliabilities, the intraclass correlation coefficients for the total scores were.904,.959, and.968. For individual skills, the percentage concordance ranged from 73% to 100%. Regarding construct validity, there was a slightly negative Pearson correlation between total WST score and age (-.434). Gender was identified as a significant factor on multiple regression analysis (P<.001). Wheelchair users with more than 21 days of experience scored higher than those with less experience (65.0% vs 59.6%; P=.01). Participants with stroke and related disorders had a mean score (55.0%+/-13.9%) that was significantly lower than those in other diagnostic categories (P<.05). Participants using conventional wheelchairs had lower scores than those in lightweight ones (66.4% vs 75.1%; P<.001). Regarding concurrent validity, Spearman rank correlations between total WST scores and the global assessments of the wheelchair users' therapists and admission and discharge FIM instrument scores were.394,.38, and.31., Conclusions: The WST 2.4 is practical and safe, and its measurement properties are very good to excellent. Further study is needed to determine its usefulness in various clinical settings.

Objective: To test the hypothesis that an algorithm-based questionnaire version of the Wheelchair Skills Test (WST) would provide a valid assessment of manual wheelchair skills., Design: Within-participant comparisons., Setting: Rehabilitation center in Nova Scotia, Canada., Participants: Twenty wheelchair users, 11 with musculoskeletal and 9 with neurologic disorders, with a wide range of wheelchair experience (1wk-20y)., Intervention: Each participant completed the questionnaire (WST-Q) and then the objective skills testing (WST, version 2.4)., Main Outcome Measure: The WST-Q consisted of 3 components, reported as separate versions: the knowledge version (WST-Q [K]) (structured oral questions only); the visual-aid version (WST-Q [VA]) (visual aids added for 6 of the skills); and the categorical perceived-ability version (WST-Q [PA])., Results: The mean total percentage scores for the WST-Q (K), WST-Q (VA), WST-Q (PA), and WST were 60.5%, 62.2%, 64.0%, and 59.8%, respectively. Only the WST-Q (PA) differed significantly from the WST (P<.05). Positive correlations existed between the objective WST and the WST-Q (K) (r=.91), WST-Q (VA) (r=.91), and WST-Q (PA) (r=.83). The percentage agreement on the individual skill scores ranged from 55% to 100%., Conclusions: The algorithm-based WST-Q has excellent concurrent validity in comparison with objective testing, when assessing the overall manual wheelchair skill levels of wheelchair users with a wide range of experience. It may be useful as a screening tool or when objective testing is impractical.

Purpose: To test the hypothesis that wheelchair users experience more discomfort when holding their necks in extended and/or rotated positions than when in their self-selected most comfortable positions (MCPs)., Methods: We studied 20 wheelchair users, first determining their MCPs with the eyes closed. Then, subjects assumed and maintained (for 5 min each) four neck positions in random order: level (L) and elevated (E), both straight ahead of the subject (S) and with the neck rotated (R). We measured neck extension angles (from digital photographs) and neck discomfort (using visual analogue scales [VAS], in %)., Results: The mean neck-extension angles were MCP - 2.6 degrees, LS 9.5 degrees, LR 8.1 degrees, ES 23.9 degrees and ER 25.4 degrees (ANOVA p < 0.0001). The mean VAS neck discomfort scores were LS 5.7%, LR 17.4%, ES 24.0% and ER 34.1% (ANOVA p < 0.0001)., Conclusions: Sustained extension and rotation of the neck, alone or in combination, increase the neck discomfort of wheelchair users. The MCP for most wheelchair users is straight ahead with the neck slightly flexed, about 11 degrees and 27 degrees more flexed, respectively, than when looking at an average-height sitting or standing person. These findings have implications for wheelchair design, the behaviour of clinicians and wheelchair users, and the built environment.

Objective: To test the hypothesis that a brief, formalized period of additional wheelchair skills training is safe and results in significantly greater improvements in wheelchair skills performance than a standard rehabilitation program., Design: Randomized controlled trial., Setting: Rehabilitation center., Participants: Thirty-five wheelchair users (20 with musculoskeletal disorders, 15 with neurologic disorders) admitted for initial rehabilitation. Subjects' mean age +/- standard deviation (SD) was 59+/-18.3 years., Intervention: Subjects randomly allocated to the treatment group participated in the Wheelchair Skills Training Program (WSTP), averaging 4.5+/-1.5 training sessions, each 30 minutes long. Subjects in the control group did not receive any wheelchair skills training beyond that given in a typical rehabilitation stay., Main Outcome Measures: Wheelchair Skills Test (WST), version 2.4, before and after training. Changes in total percentage WST score and individual skill scores were examined., Results: There were no adverse incidents. The control group's mean percentage score +/- SD increased from 60.1%+/-14.4% to 64.9%+/-13.3%, an 8% improvement of the posttest relative to the pretest (P=.01). The WSTP group's mean score increased from 64.9%+/-9.4% to 80.9%+/-5.6%, a 25% improvement of the posttest relative to the pretest (P<.000). The WSTP group showed significantly greater improvements than the control group (P<.000). Among the specific skills, significantly greater improvements were seen in the WSTP group for the gravel and high-curb descent skills (P<.001)., Conclusions: The WSTP is safe and practical and has a clinically significant effect on the independent wheeled mobility of new wheelchair users. These findings have implications for the standards of care in rehabilitation programs.

Peer review, although the standard for evaluating scientific research, is not without flaws. Peer reviewers have been shown to be inconsistent and to miss major strengths and deficiencies in studies. Both reviewer and author biases, including conflicts of interest and positive outcome publication biases, are frequent topics of study and debate. Additional concerns have been raised regarding inappropriate authorship and adequate reporting of the ethical process involving human and animal experimentation. Despite these issues, a good peer review can provide positive feedback to authors and improve the quality of research reported in medical journals. This article reviews some issues and points of concern regarding the peer-review process, and it suggests guidelines for new (and established) reviewers in the area of physical medicine and rehabilitation. It also provides suggestions for editorial considerations and improvements in the peer-review process for physical medicine and rehabilitation research journals.

Objectives: To test the hypotheses that prosthesis-wearing people with lower-limb amputations, using 2-wheeled walkers (TWW) versus 4-footed walkers (FFW), (1) walk faster, (2) walk with fewer interruptions, (3) walk no less safely, and (4) prefer the TWW., Design: Within-subject comparisons., Setting: Rehabilitation center., Participants: Twenty prosthesis-wearing people with lower-limb amputations (13 men, 7 women) with a mean age +/- standard deviation of 69+/-13 years. Of the subjects, 11 had unilateral transfemoral amputations, 7 had unilateral transtibial amputations, and 2 had bilateral transtibial amputations., Intervention: Participants were trained to use both walkers., Main Outcome Measures: Five-meter walking velocity, gait pattern, need for spotter intervention, foot position with respect to the base of support of the walker, and subject preference., Results: Subjects walked 28.5% faster when using the TWW (P=.000). During gait cycles, 100% of subjects brought the FFW to a complete halt, whereas only 55%, particularly subjects with transfemoral amputations, halted the TWW (P=.008). There was no difference in the need for spotter intervention. Subjects with unilateral amputations placed their feet significantly more anteriorly within the walker base of support when using an FFW (P=.000). Fourteen subjects preferred the TWW, and 6 chose the FFW (not significant)., Conclusion: The TWW allows prosthesis-wearing people with lower-limb amputations, especially those with transtibial amputations, to walk more quickly and with less interruption, but no less safely, than the FFW. The findings have implications for ambulation training and the prescription of ambulation aids.

Objective: To test the hypothesis that subjective estimates of the ability to perform manual wheelchair skills, by wheelchair users and the therapists working with them, accurately reflect the results of objective testing., Design: Within-subject comparisons., Setting: Kinesiologic laboratory in a rehabilitation center., Participants: Twenty-one wheelchair users and their therapists., Interventions: The wheelchair users and their therapists subjectively estimated how the wheelchair users would perform manual wheelchair skills, followed by an objective assessment., Main Outcome Measures: Wheelchair Skills Test (WST, version 2.4), a set of 50 standardized skills., Results: The Spearman correlation coefficients between the total objective and subjective scores were.95 for the wheelchair users and.75 for the therapists. The mean difference between the total objective and subjective scores was statistically significant (P=.0002) for the wheelchair users (who overestimated their abilities by an average of 17.9%). The percentage concordance between subjective and objective scores for individual skills ranged from 57.1% to 100% for the wheelchair users and 50% to 100% for the therapists, with 25% and 35% of skills, respectively, for which there were no statistically significant associations (at a Bonferroni-adjusted alpha level of.001) between the objective and subjective scores. The skills that were misestimated by both were moving the armrests away, reaching a high object, transferring out of and into the wheelchair, folding the wheelchair, incline ascent, negotiation of gravel and irregular surfaces, and small curb ascent., Conclusion: Although subjective ratings by wheelchair users and their therapists provide excellent and good estimates respectively of overall manual wheelchair abilities, objective testing should be performed when accurate assessments of many specific manual wheelchair skills are required.

Objective: To evaluate the practicality, safety, reliability, validity, and usefulness of a new Wheelchair Skills Test (WST)., Design: A pilot study with within-subject comparisons., Setting: Rehabilitation center., Patients: Twenty-four wheelchair users (11 with amputations, 4 with stroke, 3 with musculoskeletal disorders, 3 with spinal cord injury, 3 with neuromuscular disorders)., Intervention: The WST., Main Outcome Measures: Subjects were videotaped while performing 33 skills twice (>10d apart). Their ability to perform each skill was rated on a 3-point ordinal scale. The test-retest, intra-, and interrater reliabilities were determined. Each subject's occupational therapist completed a visual analog scale (VAS), reflecting a global rating of the subject's manual wheelchair skills. We assessed validity by evaluating whether the WST detected expected changes (construct validity) and how well the total WST scores correlated with the occupational therapists' global ratings (concurrent validity). Each occupational therapist also used a VAS to quantify the usefulness of the WST., Results: The mean time required to administer the WST was 29 minutes. There were no adverse incidents. For the test-retest, intra-, and interrater reliabilities, the correlations for the total scores were .65 (P =.001), .96 (P <.001), and .95 (P <.001), respectively. The 9 therapists unanimously endorsed 30 (91%) of the 33 WST skills. The correlation between the mean changes in the WST and global rating scores was .45 (P <.05). There was a slight negative relationship between total WST score and age (P <.05). There were no significant differences related to the diagnoses accounting for wheelchair use. Wheelchair users with more than 3 weeks of experience with their wheelchairs scored higher than those with less experience (P =.0085). The correlations between the WST and global rating scores ranged from .40 to .54 (P <.05). Through Rasch analysis, we eliminated 6 skills, with the remaining skills comprising a unidimensional screening test of wheelchair ability. The mean VAS score for perceived usefulness was 59%., Conclusions: The WST is practical, safe, well tolerated, exhibits good to excellent reliability, excellent content validity, fair construct and concurrent validity, and moderate usefulness. This pilot study makes an important contribution toward meeting the need for a well-validated outcome measure of manual wheelchair ability., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)